1. Stroke Mark Sudlow Consultant and Senior Lecturer
Stroke Northumbria/NHCT/University of Newcastle

2. Money talks NAO estimates of cost of stroke £7 billion annually
Of which £2.2 billion are direct costs to NHS
Cf £1.9 billion for coronary heart disease
Incidence the same as coronary heart disease – but greater associated disability
Recommend ways to save money
DOH obliged to make formal response via Public Accounts Committee
NAO to review progress

3. NAO Recommend Faster access to specialist care for patients with TIA
High risk on same day
Lower risk within a week maximum
Faster access to specialist stroke care
Acute stroke units
Early scanning – 24 hours maximum
Thrombolysis - ?10% target and timed benchmarks for onset to needle
Better long term care provision

4. Response from DOH
Stroke is no longer under Elderly or Long Term Conditions but under Vascular Disease
Working parties set up to look at recommendations on changing provision of care
NICE asked to fast track guidelines
Intercollegiate Acute Stroke and TIA Guidelines

5. Transient Ischaemic Attack
High early risk and effective early treatment

6. Risk in Transient Ischaemic Attack
Risk of completed stroke within a week = 10%
Risk > 20% if
More than one TIA in 7 days
3 or more of
BP > 140/90
Unilateral weakness of speech disturbance
Duration > 60 mins
Diabetes
The unstable angina of the brain

7. Effective treatment Aspirin 75 mg od – reduces risk by 25%
Dipyridamole MR 200mg bd – reduces risk by further 20% when added to aspirin
Cholesterol reduction
Blood pressure reduction
Smoking
Exercise
Alcohol

8. No surgery
Surgery
< 2 weeks
31.5%
6.9%
2-4 weeks
21.7%
8.4%
4-12 weeks
17.6%
7.1%
>12 weeks
15.6%
7.7%

9. What to do ..
Identify high risk patients and refer for urgent admission
More than one TIA in 7 days
3 or more of
BP > 140/90
Unilateral weakness of speech disturbance
Duration > 60 mins
Diabetes
Refer lower risk patient urgently to TIA clinic
Start aspirin and consider dipyridamole

10. What we will do .. Admit high risk patients
Start treatment
Arrange urgent imaging
Refer to vascular surgery – where they will be seen within a couple of days
See lower risk patients within a week of referral
Information
Lifestyle advice
Arrange imaging
Refer to vascular surgery – where they will be seen within two weeks

11. FAST response allows life saving treatment
Acute Stroke
FAST response allows life saving treatment

12. Evidence for specialist care
Clear evidence that hospitalisation and treatment by a coordinated specialist team improves mortality and outcome
Absolute improvement of 10%
Increasing evidence that early specialist care is the key

13. Evidence for early aspirin
1% absolute reduction in recurrence and mortality if given within 24 hours
Requires CT scan to exclude haemorrhage

14. Evidence for thrombolysis
Within 3 hours of onset of symptoms
With CT scan showing no haemorrhage
10% absolute improvement in number of patients with minimal disability

15. What to do ..
If a patient presents or calls with symptoms suggesting acute stroke
Call an ambulance

16. What we will do..
If a patient presents with stroke within thrombolysis window
Immediate referral to stroke specialist
Immediate scanning
Thrombolysis
If a patient present outside that window
Admit to specialist stroke ward
CT scan within 24 hours
Preventative treatment started early
Coordinated specialist assessment and rehabilitation
Information
Lifestyle advice

17. Secondary Prevention
Need for risk reduction as for any high risk vascular disease
With a few minor additions

18. Risk of MI, cardiac death and further stroke is similar to after MI
Strategies are broadly similar

19. Aspirin
Statin
Blood pressure – best evidence is for ACE and thiazide

20. Stroke specific Dipyridamole MR 200 mg bd for at least 2 years
Risk of further stroke is particularly high with atrial fibrillation
15% absolute per annum
Benefits of warfarin highest in this group
Risk of further stroke is particularly high with carotid stenosis
Carotid ultrasound and intervention if good recovery
Particularly important in partial anterior circulation strokes

21. What to do .. Annual check Antiplatelets Blood pressure Cholesterol
Lifestyle

22. What we will do .. Arrange ongoing rehabilitation
Outpatient check at 6 weeks (as an inpatients if not discharged)
Outpatient check at six months

23. Isolation and Dependency
Life After Stroke
Isolation and Dependency

24. Information
Inclusion of function and mood in annual screening
Access to social services and rehabilitation review

26. How it should be

27. Presentation 64 year old man Sudden onset at 11 am of
Complete loss of speech
Total paralysis of right arm and leg
Called GP surgery
Advised to call 999 ambulance
Arrives hospital 11.28
No speech
Right hemianopia
Right face, arm and leg paralysis

28. Expected outcome TACI 60% 35% 5% 6% PACI 15% 20% 65% 17% POCI Dead
Dependent
Independent
Recurrence
TACI
60%
35% 5% 6%
PACI
15%
20%
65%
17%
POCI

29. CT scan 12.00
Thrombolysis 13.00
Statin that night
Aspirin and dipyridamole start the next day

30. Arrival
2 hours
7 days
Vision
Hemianopia
Quadrantanopia
Normal
Speech
Aphasia
Mild aphasia
Neglect
Total
Mild
None
Face
Total paralysis
Mild weakness
Arm
Leg

31. Carotid doppler on day 7
95% stenosis of left carotid artery
Urgent referral to vascular surgery
Seen in vascular outpatients 2 days later and arranged for urgent admission
Carotid stenting 2 weeks after stroke

32. Out of stroke unit by 10 days
Out after carotid intervention by 2 weeks after stroke
On treatment with
Aspirin
Dipyridamole
Simvastatin
Perindopril
Bendroflumethiazide

33. Cholesterol 3.2
Blood pressure 128/76
Stopped smoking
Complete recovery
Minimal ongoing risk

34. With a coordinated approach from
Ambulance service
Primary care
Emergency care
Stroke service
Vascular surgeons
We can do this

35. And save money